AR2728
Expert
I would really appreciate other coders opinions on the two following Assessments/Plan on what level of complexity is met. A surgeon believes the following assessment/plan falls under High Medical decision making due to multiple "problems". I have two seperate examples:
ASSESSEMENT/PLAN
Patient does have gastroparesis, some gastritis as well as gastroesophageal reflux. Ph studies however would suggest that her problems with her lungs are not related to reflux. She does have chronic sinus problems and sinus drainage and states that symptoms do worsen and it may be the treatment of this would be beneficial. In the interim, would continue with proton pump inhibitor, reflux precautions, small meals and head of bed elevated. Patient does have a history of chronic constipation and did have a negative colonoscopy about 2 years ago. Would continue with her Sorbitol and Amitiza as well as Milk of Magnesia. She is not requiring suppositories or enemas but would push hydration. May benefit from a bulk agent. Would continue with head of bed elevated. She did not respond well to Erythromycin and the patient is at a high risk if she was placed on Reglan. Will therefore proceed with strict reflux precautions and have her come back in 1 year for follow-up for this, her chronic constipation, chronic GI problems and to review colon screening. I did review findings and possible sources of her lung problems from 2:20 to 2:45 with the patient and her friend.
She may benefit from following up with ENT Doctor for her sinuses which may be causing her to have aspiration. Proceed with GI problems as per above. Continue with Zantac, Protonix, reflux precautions, cathartics in 1 year
ASSESSMENT/PLAN
Male with multiple clinical problems as per above. The diarrhea has resolved with antibiotics and fiber and appears to be due to irritable bowel plus infection. Patient’s cramps are also resolved with this and appear to be due to the irritable bowel. Continue on fiber and hydration. With his increased flatus, I have recommended he start Beano. Patient’s epigastric and bilateral upper quadrant pain are better with fiber as well as his Kapidex. He is having no swallowing problems. He is to continue to treat his sinuses as per Dr. . He is to continue with his reflux precautions. He did have significant erosions and had hypochromic red blood cells. Will recheck his CBC and stool guaiacs. If he is stool guaiac positive, particularly if he still has hypochromic indices, will proceed with upper endoscopy with lower endoscopy if this is negative. If the patient’s stools are guaiac negative, and he continues with hypochromic indices, will simply start him on Iron and recheck his labs in 3 months. If his hypochromic indices have resolved and he has no blood in his stools, will simply continue with the above treatments and have him come back for follow-up in 3 months to see if we cannot wean him down to a lower strength Proton pump inhibitor. Continue to follow him for his sinuses as per above. Patient is only 27 and has no family history of colon cancer. If his stools are guaiac negative, no further workup would be indicated. His diarrhea appears to be secondary to irritable bowel plus or minus colitis with infection.
ASSESSEMENT/PLAN
Patient does have gastroparesis, some gastritis as well as gastroesophageal reflux. Ph studies however would suggest that her problems with her lungs are not related to reflux. She does have chronic sinus problems and sinus drainage and states that symptoms do worsen and it may be the treatment of this would be beneficial. In the interim, would continue with proton pump inhibitor, reflux precautions, small meals and head of bed elevated. Patient does have a history of chronic constipation and did have a negative colonoscopy about 2 years ago. Would continue with her Sorbitol and Amitiza as well as Milk of Magnesia. She is not requiring suppositories or enemas but would push hydration. May benefit from a bulk agent. Would continue with head of bed elevated. She did not respond well to Erythromycin and the patient is at a high risk if she was placed on Reglan. Will therefore proceed with strict reflux precautions and have her come back in 1 year for follow-up for this, her chronic constipation, chronic GI problems and to review colon screening. I did review findings and possible sources of her lung problems from 2:20 to 2:45 with the patient and her friend.
She may benefit from following up with ENT Doctor for her sinuses which may be causing her to have aspiration. Proceed with GI problems as per above. Continue with Zantac, Protonix, reflux precautions, cathartics in 1 year
ASSESSMENT/PLAN
Male with multiple clinical problems as per above. The diarrhea has resolved with antibiotics and fiber and appears to be due to irritable bowel plus infection. Patient’s cramps are also resolved with this and appear to be due to the irritable bowel. Continue on fiber and hydration. With his increased flatus, I have recommended he start Beano. Patient’s epigastric and bilateral upper quadrant pain are better with fiber as well as his Kapidex. He is having no swallowing problems. He is to continue to treat his sinuses as per Dr. . He is to continue with his reflux precautions. He did have significant erosions and had hypochromic red blood cells. Will recheck his CBC and stool guaiacs. If he is stool guaiac positive, particularly if he still has hypochromic indices, will proceed with upper endoscopy with lower endoscopy if this is negative. If the patient’s stools are guaiac negative, and he continues with hypochromic indices, will simply start him on Iron and recheck his labs in 3 months. If his hypochromic indices have resolved and he has no blood in his stools, will simply continue with the above treatments and have him come back for follow-up in 3 months to see if we cannot wean him down to a lower strength Proton pump inhibitor. Continue to follow him for his sinuses as per above. Patient is only 27 and has no family history of colon cancer. If his stools are guaiac negative, no further workup would be indicated. His diarrhea appears to be secondary to irritable bowel plus or minus colitis with infection.